At the edge of chaos. A prospective case study of six Australian general practices negotiating the COVID-19 pandemic.

Context: The COVID-19 pandemic has transformed the delivery of health care. Its rapid onset and progressive course challenged primary care practices to generate rapid solutions to unique circumstances. Melbourne was the focus of the pandemic in Australia and was an ideal setting to understand how general practices prepare for, and respond to, public health emergencies.

Objective: We sought to a) characterise how general practices modified their clinical and organisational routines in response to the 2020 coronavirus pandemic; and b) identify the contextual, organisational and individual factors that influenced these changes.

Study Design: Prospective qualitative case study of 6 urban general practices. Participatory approach informed by complexity theory and Miller’s Relationship Centred Development model. Participant GP investigators helped design the study, aided recruitment, prepared structured summaries of practice structure and function and diarised their work related experiences. Social scientists interviewed GPs, practice managers, nurses, receptionists on three occasions. Practices gave feedback on preliminary findings during end of study group meetings, and participant GP investigators helped analyse and interpret findings.

Setting / Population: 6 Melbourne general practices between April 2020 to February 2021. Practices included a corporate practice, a community health centre and four privately owned practices with between 3 and 10 FTE GPs. We conducted 58 interviews with GPs, practice nurses and administrative staff.

Results: All practices incorporated changes to triage, clinical, infection control and organisational routines, in particular around telehealth. While collaboration and trust increased within several practices, others fragmented - leaving staff isolated and demoralised. Financial and organisational stability, collaborative problem solving, creative leadership, and communication (internally and with the broader healthcare sector) were major influences on practices’ ability to negotiate the pandemic.

Conclusions: This study demonstrates the utility of the Relationship Centred Development model, and reinforces the potential of clinician participation in design, conduct and analysis. Primary care’s ability to respond to similar challenges would benefit from supportive financial models (with decreased reliance on fee for service), investment in leadership, and an acknowledgement that sensemaking is an ongoing social activity.